White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Injection, therapeutic (eg, local anesthetic, corticosteroid), carpal tunnel

Facility

$10,000.00

Service Code	CPT 20526
Hospital Charge Code	36020526
Hospital Revenue Code	360
Min. Negotiated Rate	$5.97
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Medicare	$406.30
Rate for Payer: Amerigroup CHIP/Medicaid	$36.54
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$270.87
Rate for Payer: Amerigroup Medicare	$270.87
Rate for Payer: BCBS of TX Blue Advantage	$69.30
Rate for Payer: BCBS of TX Blue Essentials	$83.00
Rate for Payer: BCBS of TX Medicare	$270.87
Rate for Payer: BCBS of TX PPO	$104.58
Rate for Payer: Cigna Commercial	$613.60
Rate for Payer: Cigna Medicaid	$36.54
Rate for Payer: Cigna Medicare	$270.87
Rate for Payer: Employer Direct Commercial	$270.87
Rate for Payer: Humana Medicare/TRICARE	$270.87
Rate for Payer: Molina CHIP/Medicaid	$36.54
Rate for Payer: Molina Dual Medicare/Medicaid	$270.87
Rate for Payer: Molina Medicare	$270.87
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$36.54
Rate for Payer: Scott and White EPO/PPO	$5.97
Rate for Payer: Scott and White Medicare	$270.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$36.54
Rate for Payer: Superior Health Plan EPO	$270.87
Rate for Payer: Superior Health Plan Medicare	$270.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$270.87
Rate for Payer: Universal American Medicare	$270.87
Rate for Payer: Wellcare Medicare	$270.87
Rate for Payer: Wellmed Medicare	$270.87

INJECTOR, UTERINE MANIPULATOR BLLN TIPPD 13''''L DISP -- DHF

Facility

$165.36

Hospital Charge Code	81778250
Hospital Revenue Code	270
Min. Negotiated Rate	$14.88
Max. Negotiated Rate	$107.48
Rate for Payer: Aetna Commercial	$90.95
Rate for Payer: Amerigroup CHIP/Medicaid	$14.88
Rate for Payer: BCBS of TX Blue Advantage	$49.61
Rate for Payer: BCBS of TX Blue Essentials	$59.53
Rate for Payer: BCBS of TX PPO	$66.14
Rate for Payer: Cash Price	$145.52
Rate for Payer: Multiplan Auto	$107.48
Rate for Payer: Multiplan Commercial	$107.48
Rate for Payer: Multiplan Workers Comp	$107.48
Rate for Payer: Scott and White EPO/PPO	$82.68
Rate for Payer: Superior Health Plan EPO	$22.49

INJECTOR, UTERINE MANIPULATOR BLLN TIPPD 13''''L DISP -- DHF

Facility

$165.36

Hospital Charge Code	81778250
Hospital Revenue Code	270
Rate for Payer: Cash Price	$145.52

INJECT PULM ART HRT CATH

Facility

$2,230.00

Service Code	CPT 93568
Hospital Charge Code	4613571
Hospital Revenue Code	481
Min. Negotiated Rate	$200.70
Max. Negotiated Rate	$7,287.00
Rate for Payer: Aetna Commercial	$7,287.00
Rate for Payer: Amerigroup CHIP/Medicaid	$200.70
Rate for Payer: Cash Price	$1,962.40
Rate for Payer: Cash Price	$1,962.40
Rate for Payer: Multiplan Auto	$1,449.50
Rate for Payer: Multiplan Commercial	$1,449.50
Rate for Payer: Multiplan Workers Comp	$1,449.50
Rate for Payer: Scott and White EPO/PPO	$1,115.00
Rate for Payer: Superior Health Plan EPO	$303.28

INJECT PULM ART HRT CATH

Facility

$2,230.00

Service Code	CPT 93568
Hospital Charge Code	4613571
Hospital Revenue Code	481
Rate for Payer: Cash Price	$1,962.40

INJ EPID BLD PATCH

Facility

$1,339.00

Service Code	CPT 62273
Hospital Charge Code	4610101
Hospital Revenue Code	360
Rate for Payer: Cash Price	$1,178.32

INJ EPID BLD PATCH

Facility

$1,339.00

Service Code	CPT 62273
Hospital Charge Code	4610101
Hospital Revenue Code	360
Min. Negotiated Rate	$13.95
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$1,400.00
Rate for Payer: Aetna Medicare	$948.68
Rate for Payer: Amerigroup CHIP/Medicaid	$262.86
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$632.45
Rate for Payer: Amerigroup Medicare	$632.45
Rate for Payer: BCBS of TX Blue Advantage	$1,043.83
Rate for Payer: BCBS of TX Blue Essentials	$1,250.10
Rate for Payer: BCBS of TX Medicare	$632.45
Rate for Payer: BCBS of TX PPO	$1,575.13
Rate for Payer: Cash Price	$1,178.32
Rate for Payer: Cash Price	$1,178.32
Rate for Payer: Cigna Commercial	$1,432.68
Rate for Payer: Cigna Medicaid	$262.86
Rate for Payer: Cigna Medicare	$632.45
Rate for Payer: Employer Direct Commercial	$632.45
Rate for Payer: Humana Medicare/TRICARE	$632.45
Rate for Payer: Molina CHIP/Medicaid	$262.86
Rate for Payer: Molina Dual Medicare/Medicaid	$632.45
Rate for Payer: Molina Medicare	$632.45
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$262.86
Rate for Payer: Scott and White EPO/PPO	$13.95
Rate for Payer: Scott and White Medicare	$632.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$262.86
Rate for Payer: Superior Health Plan EPO	$632.45
Rate for Payer: Superior Health Plan Medicare	$632.45
Rate for Payer: Universal American Dual Medicare/Medicaid	$632.45
Rate for Payer: Universal American Medicare	$632.45
Rate for Payer: Wellcare Medicare	$632.45
Rate for Payer: Wellmed Medicare	$632.45

INJ EPID LUMB/CAUD

Facility

$2,090.00

Service Code	CPT 62323
Hospital Charge Code	4617682
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,839.20

INJ EPID LUMB/CAUD

Facility

$2,090.00

Service Code	CPT 62323
Hospital Charge Code	4617682
Hospital Revenue Code	361
Min. Negotiated Rate	$13.95
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$1,400.00
Rate for Payer: Aetna Medicare	$948.68
Rate for Payer: Amerigroup CHIP/Medicaid	$262.86
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$632.45
Rate for Payer: Amerigroup Medicare	$632.45
Rate for Payer: BCBS of TX Blue Advantage	$1,043.83
Rate for Payer: BCBS of TX Blue Essentials	$1,250.10
Rate for Payer: BCBS of TX Medicare	$632.45
Rate for Payer: BCBS of TX PPO	$1,575.13
Rate for Payer: Cash Price	$1,839.20
Rate for Payer: Cash Price	$1,839.20
Rate for Payer: Cigna Commercial	$1,432.68
Rate for Payer: Cigna Medicaid	$262.86
Rate for Payer: Cigna Medicare	$632.45
Rate for Payer: Employer Direct Commercial	$632.45
Rate for Payer: Humana Medicare/TRICARE	$632.45
Rate for Payer: Molina CHIP/Medicaid	$262.86
Rate for Payer: Molina Dual Medicare/Medicaid	$632.45
Rate for Payer: Molina Medicare	$632.45
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$262.86
Rate for Payer: Scott and White EPO/PPO	$13.95
Rate for Payer: Scott and White Medicare	$632.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$262.86
Rate for Payer: Superior Health Plan EPO	$632.45
Rate for Payer: Superior Health Plan Medicare	$632.45
Rate for Payer: Universal American Dual Medicare/Medicaid	$632.45
Rate for Payer: Universal American Medicare	$632.45
Rate for Payer: Wellcare Medicare	$632.45
Rate for Payer: Wellmed Medicare	$632.45

INJ NEPHROGRM EXIS ACC

Facility

$1,616.00

Service Code	CPT 50431
Hospital Charge Code	4617665
Hospital Revenue Code	361
Min. Negotiated Rate	$13.78
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$1,400.00
Rate for Payer: Aetna Medicare	$937.10
Rate for Payer: Amerigroup CHIP/Medicaid	$145.44
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$624.73
Rate for Payer: Amerigroup Medicare	$624.73
Rate for Payer: BCBS of TX Blue Advantage	$929.41
Rate for Payer: BCBS of TX Blue Essentials	$1,113.06
Rate for Payer: BCBS of TX Medicare	$624.73
Rate for Payer: BCBS of TX PPO	$1,402.46
Rate for Payer: Cash Price	$1,422.08
Rate for Payer: Cash Price	$1,422.08
Rate for Payer: Cash Price	$1,422.08
Rate for Payer: Cigna Commercial	$1,415.20
Rate for Payer: Cigna Medicare	$624.73
Rate for Payer: Employer Direct Commercial	$624.73
Rate for Payer: Humana Medicare/TRICARE	$624.73
Rate for Payer: Molina Dual Medicare/Medicaid	$624.73
Rate for Payer: Molina Medicare	$624.73
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Scott and White EPO/PPO	$13.78
Rate for Payer: Scott and White Medicare	$624.73
Rate for Payer: Superior Health Plan EPO	$624.73
Rate for Payer: Superior Health Plan Medicare	$624.73
Rate for Payer: Universal American Dual Medicare/Medicaid	$624.73
Rate for Payer: Universal American Medicare	$624.73
Rate for Payer: Wellcare Medicare	$624.73
Rate for Payer: Wellmed Medicare	$624.73

INJ NEPHROGRM EXIS ACC

Facility

$1,616.00

Service Code	CPT 50431
Hospital Charge Code	4617665
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,422.08

INJ RT VENTR/ATRIAL ANGIO

Facility

$2,150.00

Service Code	CPT 93566
Hospital Charge Code	2350069
Hospital Revenue Code	481
Rate for Payer: Cash Price	$1,892.00

INJ RT VENTR/ATRIAL ANGIO

Facility

$2,150.00

Service Code	CPT 93566
Hospital Charge Code	2350069
Hospital Revenue Code	481
Min. Negotiated Rate	$193.50
Max. Negotiated Rate	$7,287.00
Rate for Payer: Aetna Commercial	$7,287.00
Rate for Payer: Amerigroup CHIP/Medicaid	$193.50
Rate for Payer: Cash Price	$1,892.00
Rate for Payer: Cash Price	$1,892.00
Rate for Payer: Multiplan Auto	$1,397.50
Rate for Payer: Multiplan Commercial	$1,397.50
Rate for Payer: Multiplan Workers Comp	$1,397.50
Rate for Payer: Scott and White EPO/PPO	$1,075.00
Rate for Payer: Superior Health Plan EPO	$292.40

INPATIENT APRDRG 0011: LIVER TRANSPLANT &/OR INTESTINAL TRANSPLANT

Facility

$8.44

Service Code	APR-DRG 0011
Hospital Charge Code	APRDRG 0011
Min. Negotiated Rate	$8.44
Max. Negotiated Rate	$8.44
Rate for Payer: Amerigroup CHIP/Medicaid	$8.44
Rate for Payer: Cigna Medicaid	$8.44
Rate for Payer: Molina CHIP/Medicaid	$8.44
Rate for Payer: Parkland Medicaid	$8.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8.44

INPATIENT APRDRG 0012: LIVER TRANSPLANT &/OR INTESTINAL TRANSPLANT

Facility

$8.77

Service Code	APR-DRG 0012
Hospital Charge Code	APRDRG 0012
Min. Negotiated Rate	$8.77
Max. Negotiated Rate	$8.77
Rate for Payer: Amerigroup CHIP/Medicaid	$8.77
Rate for Payer: Cigna Medicaid	$8.77
Rate for Payer: Molina CHIP/Medicaid	$8.77
Rate for Payer: Parkland Medicaid	$8.77
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8.77

INPATIENT APRDRG 0013: LIVER TRANSPLANT &/OR INTESTINAL TRANSPLANT

Facility

$11.42

Service Code	APR-DRG 0013
Hospital Charge Code	APRDRG 0013
Min. Negotiated Rate	$11.42
Max. Negotiated Rate	$11.42
Rate for Payer: Amerigroup CHIP/Medicaid	$11.42
Rate for Payer: Cigna Medicaid	$11.42
Rate for Payer: Molina CHIP/Medicaid	$11.42
Rate for Payer: Parkland Medicaid	$11.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11.42

INPATIENT APRDRG 0014: LIVER TRANSPLANT &/OR INTESTINAL TRANSPLANT

Facility

$22.16

Service Code	APR-DRG 0014
Hospital Charge Code	APRDRG 0014
Min. Negotiated Rate	$22.16
Max. Negotiated Rate	$22.16
Rate for Payer: Amerigroup CHIP/Medicaid	$22.16
Rate for Payer: Cigna Medicaid	$22.16
Rate for Payer: Molina CHIP/Medicaid	$22.16
Rate for Payer: Parkland Medicaid	$22.16
Rate for Payer: Superior Health Plan CHIP/Medicaid	$22.16

INPATIENT APRDRG 0021: HEART &/OR LUNG TRANSPLANT

Facility

$9.48

Service Code	APR-DRG 0021
Hospital Charge Code	APRDRG 0021
Min. Negotiated Rate	$9.48
Max. Negotiated Rate	$9.48
Rate for Payer: Amerigroup CHIP/Medicaid	$9.48
Rate for Payer: Cigna Medicaid	$9.48
Rate for Payer: Molina CHIP/Medicaid	$9.48
Rate for Payer: Parkland Medicaid	$9.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9.48

INPATIENT APRDRG 0022: HEART &/OR LUNG TRANSPLANT

Facility

$12.24

Service Code	APR-DRG 0022
Hospital Charge Code	APRDRG 0022
Min. Negotiated Rate	$12.24
Max. Negotiated Rate	$12.24
Rate for Payer: Amerigroup CHIP/Medicaid	$12.24
Rate for Payer: Cigna Medicaid	$12.24
Rate for Payer: Molina CHIP/Medicaid	$12.24
Rate for Payer: Parkland Medicaid	$12.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12.24

INPATIENT APRDRG 0023: HEART &/OR LUNG TRANSPLANT

Facility

$15.24

Service Code	APR-DRG 0023
Hospital Charge Code	APRDRG 0023
Min. Negotiated Rate	$15.24
Max. Negotiated Rate	$15.24
Rate for Payer: Amerigroup CHIP/Medicaid	$15.24
Rate for Payer: Cigna Medicaid	$15.24
Rate for Payer: Molina CHIP/Medicaid	$15.24
Rate for Payer: Parkland Medicaid	$15.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15.24

INPATIENT APRDRG 0024: HEART &/OR LUNG TRANSPLANT

Facility

$61.87

Service Code	APR-DRG 0024
Hospital Charge Code	APRDRG 0024
Min. Negotiated Rate	$61.87
Max. Negotiated Rate	$61.87
Rate for Payer: Amerigroup CHIP/Medicaid	$61.87
Rate for Payer: Cigna Medicaid	$61.87
Rate for Payer: Molina CHIP/Medicaid	$61.87
Rate for Payer: Parkland Medicaid	$61.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$61.87

INPATIENT APRDRG 0041: TRACHEOSTOMY W MV 96+ HOURS W EXTENSIVE PROCEDURE

Facility

$8.84

Service Code	APR-DRG 0041
Hospital Charge Code	APRDRG 0041
Min. Negotiated Rate	$8.84
Max. Negotiated Rate	$8.84
Rate for Payer: Amerigroup CHIP/Medicaid	$8.84
Rate for Payer: Cigna Medicaid	$8.84
Rate for Payer: Molina CHIP/Medicaid	$8.84
Rate for Payer: Parkland Medicaid	$8.84
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8.84

INPATIENT APRDRG 0042: TRACHEOSTOMY W MV 96+ HOURS W EXTENSIVE PROCEDURE

Facility

$10.77

Service Code	APR-DRG 0042
Hospital Charge Code	APRDRG 0042
Min. Negotiated Rate	$10.77
Max. Negotiated Rate	$10.77
Rate for Payer: Amerigroup CHIP/Medicaid	$10.77
Rate for Payer: Cigna Medicaid	$10.77
Rate for Payer: Molina CHIP/Medicaid	$10.77
Rate for Payer: Parkland Medicaid	$10.77
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10.77

INPATIENT APRDRG 0043: TRACHEOSTOMY W MV 96+ HOURS W EXTENSIVE PROCEDURE

Facility

$16.47

Service Code	APR-DRG 0043
Hospital Charge Code	APRDRG 0043
Min. Negotiated Rate	$16.47
Max. Negotiated Rate	$16.47
Rate for Payer: Amerigroup CHIP/Medicaid	$16.47
Rate for Payer: Cigna Medicaid	$16.47
Rate for Payer: Molina CHIP/Medicaid	$16.47
Rate for Payer: Parkland Medicaid	$16.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16.47

INPATIENT APRDRG 0044: TRACHEOSTOMY W MV 96+ HOURS W EXTENSIVE PROCEDURE

Facility

$25.61

Service Code	APR-DRG 0044
Hospital Charge Code	APRDRG 0044
Min. Negotiated Rate	$25.61
Max. Negotiated Rate	$25.61
Rate for Payer: Amerigroup CHIP/Medicaid	$25.61
Rate for Payer: Cigna Medicaid	$25.61
Rate for Payer: Molina CHIP/Medicaid	$25.61
Rate for Payer: Parkland Medicaid	$25.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$25.61

Know your out-of-pocket cost for care.

All Charges